Smart NC,
North Carolina Department of Insurance
The state Insurance Department models a “new way of doing business” to resolve consumers’ problems.
Program Structure and Services
The North Carolina consumer assistance program, called Health Insurance Smart NC, operates out of a central office housed in the Department of Insurance in Raleigh, with two regional offices in New Bern and Asheville. The program assists residents with all types of coverage, including public, private, and self-funded plans. It also helps consumers who are uninsured. Program specialists help consumers understand their rights and responsibilities, identify affordable insurance options, enroll in coverage, file complaints, handle internal and external appeals for claims that have been denied based on medical necessity, and resolve other issues related to health insurance.
Smart NC is staffed by six health insurance specialists, four in the central office and one in each of the regional offices, as well as two clinical review analysts in the central office. These health insurance specialists bring varied types of expertise to the program, ranging from clinical experience to program administration. Health insurance specialists receive rigorous training on provisions of the Affordable Care Act, state and federal laws pertaining to appeals and grievances, claims processing, and eligibility criteria and renewal processes for public insurance programs. Additional training is provided as needed by representatives of federal and state agencies, such as the IRS and the North Carolina Community Health Center Association. Each specialist is mentored by a review analyst before beginning to provide counseling to consumers.
Smart NC uses a case management approach to consumer assistance, which emphasizes providing individualized advocacy and counseling case by case, rather than using scripts to respond to consumer inquiries. This approach also includes actively intervening with plans, program administrators, and employers to resolve consumer issues.
Case managers take a proactive approach to resolving complaints quickly. When a consumer requests assistance online or via mail or fax, a specialist immediately contacts the consumer to establish a relationship. Many times, a case manager will set up a teleconference that includes both the consumer and the insurance company to talk through the problem and determine the reason for the insurance company’s decision, whether it was an administrative error, a denial of coverage based on medical necessity, or a dispute about the benefits provided under the plan. Many cases are resolved without filing an appeal.
If an appeal is necessary, the case manager helps the consumer assemble the materials needed for the appeal, including drafting the appeal letter, collecting documentation, and contacting the provider and insurance carrier to request additional information. While the case managers are doing this, they are also educating the consumer about their rights, helping them make informed decisions, and explaining the complex process of resolving complaints in a way that is understandable. When appropriate, specialists assist consumers with assessing alternative coverage options and help them make informed decisions. Specialists will also identify community or private programs that may be available to help consumers meet their health care needs.
How Did Consumer Assistance Grant Funding Improve the Insurance Department’s Services?
The Smart NC program was established using the federal consumer assistance grant of $850,000 that was awarded to the North Carolina Department of Insurance in October 2010. The Department of Insurance recruited the director of the North Carolina State Health Insurance Assistance Program (SHIP), which is also housed in the Department of Insurance and provides assistance to seniors in resolving issues with Medicare and Medicaid coverage, to create a program that could serve all North Carolina health care consumers. Smart NC built on the services that were previously provided through the Department of Insurance, but it provides assistance on a broader range of health insurance issues and has the capacity to serve more consumers. North Carolina used the first months of its grant funding to hire and train staff, develop procedures, and establish contacts in insurance companies that would enable them to resolve cases efficiently. The program started taking referrals in April 2011 and officially launched on August 9, 2011.
Before the Smart NC program was created, the Insurance Department acted only as a regulator: It could intervene in response to consumer complaints only if it determined that the insurer had broken the law, and it could administer external reviews of appeals of denials of coverage due to medical necessity. It couldn’t help consumers figure out what to do to solve problems with insurance or provide other kinds of guidance.
With the establishment of Smart NC, health care consumers experienced “a new way of doing business” at the North Carolina Department of Insurance. When consumers call Smart NC, they are assigned to a health insurance specialist or case manager who can work through the complaint with them from inquiry to resolution. Insurance specialists also work with the state Medicaid office, the state and federal high-risk pool, and the Department of Labor to address complaints related to state and federal insurance programs.
Between April and November 2011, Smart NC served 1,672 consumers who asked for help with filing complaints, enrolling in coverage, filing medical appeals, and preparing requests for external review. Over these few months, the program saw an increase in the total volume of cases involving denials due to medical necessity, and it had begun to handle a number of cases for consumers in self-insured plans. Smart NC’s operation under the umbrella of the Department of Insurance allows the program to easily report compliance issues and to track trends in consumer complaints that indicate systemic problems that should be addressed.
Public Education and Outreach
In its first year, the program conducted outreach and education to promote awareness of Smart NC services among consumer groups, nonprofits, advocacy groups, and local agencies, sharing data and information gathered from the program’s casework and updates about its services. It also established a Community Advisory Board that represents consumers, consumer-based nonprofit organizations, and other critical stakeholders to facilitate coordination and collaboration among health care advocacy efforts in North Carolina. In addition to this work, the Smart NC website provides consumer publications on a variety of health insurance topics in English and Spanish, as well as answers to frequently asked questions about health insurance.
Consumer Story
One of the calls that Smart NC received was from a man whose son was in the hospital receiving cancer treatment. While his son was hospitalized, the son’s premium for COBRA coverage had lapsed by two days, and his insurance plan cancelled his coverage. The man’s father explained that he did not know what they were going to do if his son did not have insurance coverage for the cancer treatments. A health insurance specialist filed a complaint with the COBRA plan administrator, including an explanation for the missed premium. As a result, the company reinstated his policy.
Sources
- Interview between Cheryl Fish-Parcham and Elaine Saly, Families USA, and Carla Obiol, Senior Deputy Commissioner, Ombudsman Services Group, North Carolina Department of Insurance, June 14, 2011.
- Interview between Cheryl Fish-Parcham and Elaine Saly, Families USA, and Susan Nestor, Director, Health Insurance Smart NC program, June 24, 2011.
- Health Insurance Smart NC, Trend Analysis of Cases Received: 2011, available online at http://familiesusa2.org/assets/pdfs/TrendAnalysis12-02-2011.pdf.
- Health Insurance Smart NC consumer brochures and fact sheets are available online at http://www.ncdoi.com/Smart/Smart_Publications.aspx. Answers to frequently asked health insurance questions are available online at http://www.ncdoi.com/Smart/Smart_FAQs.aspx.
PDF of this profile is available.
